Fingertip Reconstruction With Flaps

and Nail Bed Grafts

Richard E. Brown, MD, Elvin G. Zook, MD, Robert C. Russell, MD,
Springfield, IL

We retrospectively reviewed the cases of 14 fingertips reconstructed with a combination of

local or regional flaps and nail bed grafts, some of which were placed wholly or partially over
a de-epithelialized flap. Most of the fingertips sustained a crushing injury and were recon-
structed at the time of the injury. Soft tissue coverage was provided by palmar V-Y flaps in 6
cases, thenar flaps in 4, lateral V-Y flaps in 2, a Moberg flap in 1, and a cross-finger flap in 1.
Split toenail bed grafts were used in 6 cases, full-thickness nail bed grafts from the amputated
part in 6, and split nail bed grafts from the injured digit in 2. There was 1 partial graft loss and
1 partial flap loss. The remaining cases had completely successful grafts and good soft tissue
healing. Subsequent nail growth and adherence were good in all but the 1 digit requiring
secondary composite grafting. (J Hand Surg 1999;24A:345–351. Copyright © 1999 by the
American Society for Surgery of the Hand.)
Key words: Nail bed, graft, flap, fingertip.

Fingertip injuries can be treated in a variety of
ways, including simple dressing changes, shorten-
ing with primary closure, skin grafts, or closure
using various local and distant flaps. Nail bed
involvement complicates any fingertip reconstruc-
tion and may influence the selection of treatment.
Numerous local flaps have been described for soft
tissue coverage of an exposed distal phalanx.1–10
Similarly, nail bed grafts, either from the ampu-
tated part or from another digit, are routinely used
to reconstruct injured nail beds.11–13 We reviewed
over 100 nail bed grafts at our institution and
From the Division of Plastic Surgery, Southern Illinois University
School of Medicine, Springfield, IL.
Received for publication March 17, 1995; accepted in revised form
October 2, 1998.
Presented in part at the 22nd Annual Meeting of the American
Association for Hand Surgery, Washington, DC, September 1992.
No benefits in any form have been received or will be received from
a commercial party related directly or indirectly to the subject of this
article.
Reprint requests: Richard E. Brown, MD, Division of Plastic Sur-
gery, Southern Illinois University School of Medicine, Springfield
Clinic, 501 N First St, PO Box 19248, Springfield, IL 62794-9248.
Copyright © 1999 by the American Society for Surgery of the Hand
0363-5023/99/24A02-0017$3.00/0
identified 14 digits that were reconstructed acutely
with a combination of local flaps and nail bed
grafts. The present report discusses our results
with this subset of patients.
Materials and Methods
The 14 patients ranged in age from 10 to 44 years;
most were male. The index and long fingers were
most commonly injured by a variety of mechanisms,
most of a crushing nature similar in causation as
previously reported.14
Various types of flaps were used for fingertip
coverage, as shown in Table 1; V-Y advancement
flaps were most commonly used. Local or regional
pedicle flaps (ie, thenar and cross-finger) were used
in 5 patients. A Moberg flap was used in the only
patient with a thumb tip injury. In 6 cases, a portion
of the flap was de-epithelialized (epidermis removed)
to provide support for placement of the nail bed
grafts.
The source of the nail bed grafts is shown in Table
2. Full-thickness nail bed grafts were harvested from
the amputated part when available. The amputated
parts were unavailable in the majority of cases, thus

The Journal of Hand Surgery 345

346 Brown, Zook, and Russell / Nail Bed Grafts and Local Flaps
Table 1. Types of Flaps Used for
Fingertip Coverage
Palmar V-Y flap (Atasoy) 6 satisfactory (Fig. 2C). It is interesting to note that by
Thenar flap 4
Lateral V-Y flaps (Kutler) 2 placing a continuous scratch across the nail the finger
Moberg palmar advancement 1 and toe portions of her thumb nail grew at the same
Cross-finger flap 1 rate. It has been reported that the nail on the toe
necessitating a split-thickness nail bed graft from a
toe or the injured digit. One patient also underwent a
secondary reconstruction with a composite graft
from the second toe, consisting of the dorsal roof and
the germinal and sterile nail matrices.
An example of a nail bed graft placed on a de-
epithelialized portion of 4 types of flaps is given
below.
Case 1
A 37-year-old man sustained a crush injury to his
middle finger. The tip was amputated at the mid-nail
level with exposed distal phalanx (Fig. 1A). Cover-
age of the tip was achieved with bilateral V-Y Kutler
flaps (Fig. 1B). The nail bed graft was harvested
from the amputated part and placed on the de-epi-
thelialized area and the edge of the advanced flaps
(Fig. 1C). Partial necrosis of one of the V-Y flaps
occurred, but good tip coverage as well as good nail
growth and adherence was present 4 months later
(Fig. 1D and 1E). It is estimated that although short-
ening and mild palmar curvature is present, the nail
is adherent 4 mm more than it would be without the
nail bed graft.
Case 2
A 19-year-old college student sustained a crush
injury to the thumb. The tip was severely crushed
and devascularized (Fig. 2A). A Moberg volar ad-
vancement flap was used to preserve length and to
allow nail bed reconstruction. A full-thickness nail
bed graft was harvested from the crushed tip and
placed partially on a de-epithelialized portion of the
Moberg flap. The reconstructed tip healed normally
and the thumb regained good metacarpophalangeal
and interphalangeal motion. Hard nail growth oc-
curred only on the radial half of the tip, indicating
injury to the germinal matrix (Fig. 2B). To correct
this, a composite graft (ie, dorsal roof and germinal
and sterile matrices) was harvested from the second
toe and placed on the radial side of the nail bed. Two
years following the original injury, nail growth and
adherence were good and the appearance was quite
grows 4 times more slowly than the fingernail.15
Consequently, this case seems to indicate that nail
growth rate is related to the local environment rather
than inherent to the origin of the nail bed itself.
Case 3
A 15-year-old boy sustained a middle fingertip
amputation. The tip was reconstructed using a cross-
finger flap for coverage and a full-thickness sterile
matrix nail bed graft from the amputated part placed
on the de-epithelialized end of the flap (Fig. 3A). Six
months after injury he had good fingertip coverage;
there was excellent nail growth, adherence, and 6 to
7 mm of additional nail length (twice the length of
adherent nail that would have resulted without use of
the nail bed graft) (Fig. 3B).
Case 4
A 19-year-old man sustained a partial index fin-
gertip amputation. There was significant nail bed loss
and the distal phalanx was exposed (Fig. 4A). An
Atasoy-Kleinert V-Y advancement flap was used for
coverage of the tip and a split-thickness nail bed graft
was harvested from the great toe and placed over the
bone and the side of the flap to replace the missing
nail bed (Fig. 4B). Four months following injury,
there was excellent coverage, nail growth, and ad-
herence and at least an additional 5 mm of hard
adherent nail (Fig. 4C).
Results
Thirteen of 14 patients (13 digits) were available
for follow-up examination. Nail bed grafting was
successful in all cases except for a partial graft loss
in case 2 as described previously. Similarly, there
Table 2. Source of the Nail Bed Grafts
Split-thickness graft from toe 6
Full-thickness graft from amputated part 6
Split-thickness graft from injured digit 2
Composite graft from toe (secondary reconstruction) 1
 The Journal of Hand Surgery / Vol. 24A No. 2 March 1999 347

Figure 1. (A) Amputation just distal to the lunula. (B and C) Reconstruction with bilateral V-Y flaps and a full-thickness
nail bed graft from the amputated part placed on a de-epithelialized area of the flaps. (The arrows mark the junction of the
proximal nail bed and the distal nail bed graft.) (D and E) Result at 4 months. (The arrows mark the junction of the attached
and grafted nail bed.)
348 Brown, Zook, and Russell / Nail Bed Grafts and Local Flaps

was partial flap loss of a V-Y flap only in 1 case.

Long-term follow-up revealed smooth nail growth;
there was good nail adherence in all cases with the
exception of a slight ridge at the junction of the
primary and secondary grafts in case 2. All patients
were pleased with the aesthetic outcome.

Discussion
Fingertip injuries are the most common injury seen
by hand surgeons.16 These injuries frequently in-
volved both the soft tissue covering the distal pha-
lanx and the nail bed. Primary soft tissue repair and
meticulous nail bed suturing usually yield excellent
results.14 With more severe crush, or distal tip am-
putations, primary repair may not be an option with-
out shortening of the distal phalanx. Healing by
secondary intention may yield satisfactory cosmetic
and functional results in young patients or adults
with minimal tissue loss.17–22 Soft tissue coverage,
however, is generally needed when there is signifi-
cant exposure of the distal phalanx. In addition, with
amputations or avulsion injuries, nail bed tissue is
frequently needed to lengthen the repair and avoid a
short or nonadherent nail plate. For a fingernail to
function normally it must protrude 1 to 2 mm beyond
the hyponychium; otherwise, it cannot be used to

Figure 2. (A) Severe

crush of the thumb tip.
(B) Hard nail growth on
only half of the tip. (C)
Result at 2 years, after
secondary grafting with
a nonvascularized com-
posite dorsal roof, ger-
minal matrix, and sterile
matrix.
 The Journal of Hand Surgery / Vol. 24A No. 2 March 1999 349

Figure 3. (A and B) Result of tip reconstruction with a cross-finger flap and full-thickness nail bed graft from the
amputated part. (The arrows points to the junction of the attached and grafted nail bed.)

pick up small objects (needles, pins, etc) that require
hooking with the free edge of the nail.
Rose et al23 described good results with a “cap
graft,” including the composite remnant of the am-
putated palmar pulp and distal nail bed, for coverage
of such defects. Although we have had fair results
with this graft, in many instances the part is either
severely injured or not available. In such circum-
stances, the only options are primary shortening or
flap coverage with nail bed reconstruction. Shepard24
used a split-thickness graft in combination with a
volar V-Y advancement flap in 1 case with excellent
results. In addition, Saito et al13 noted the use of
“either . . . V-Y skin advancement or other types of
local skin flaps” in combination with nail bed grafts
in their 4 patients with “type III” fingertip injuries;
these investigators also had good results.
An extensive series of fingertip reconstruction us-
ing a combination of local or regional flaps and full-
or partial-thickness nail bed grafts to add length has
not been conducted. In addition, the concept of plac-
ing nail bed grafts on de-epithelialized flaps is new.
As illustrated in our cases, flaps are able to provide
soft tissue coverage as well as a vascularized bed for
the nail bed graft. Such grafts may be placed on
exposed dorsal distal phalanx, fat at the edge of the
flap, or the de-epithelialized surface of the flap. How-
ever, reasonable bony support is necessary to prevent
a hook nail deformity for which there are few good
reconstructive options other than a free vascularized
nail bed transfer.25,26 Although most of our cases
resulted in mild proximal to distal curving, a symp-
tomatic hook nail deformity was avoided in all cases.
Without the flap(s) and nail bed grafts, most would
350 Brown, Zook, and Russell / Nail Bed Grafts and Local Flaps

Figure 4. (A) Severe avulsion of the nail bed and tip and exposure of the
distal phalanx. (B) Reconstruction with a palmar V-Y flap and a split-
thickness nail bed graft from the great toe. (The arrows mark the junction of
the attached and grafted nail bed.) (C) Results at 4 months.
 The Journal of Hand Surgery / Vol. 24A No. 2 March 1999 351
have either necessitated complete nail ablation and
shortening and many would have developed severe
nail curving.
Both split nail bed grafts and full-thickness nail
bed grafts were used. It is not known how nail bed
grafts “take” or survive, but both full and split sterile
matrix grafts appear to do equally well. Full-thick-
ness grafts are only used from the amputated part
since harvest from a toe or finger would leave a
donor deformity. When another digit (toe or finger)
is used, a split graft is harvested; if done correctly,
this should not result in donor site deformity. The
decision regarding which to use is generally made
based on the availability of the amputated part as
well as on the willingness of the patient to allow split
nail bed graft harvesting from an adjacent digit or a
toe. If the amputated part is unavailable and the
patient is unwilling to have another digit violated, an
alternate reconstruction, such as complete nail abla-
tion and shortening, must be chosen.
Although objective functional data, such as from
2-point discrimination or Jebsen tests, were not ob-
tained for our patients, all were pleased with their
outcome and used their affected digit in activities of
daily living. Since near-normal or considerably more
length with minimal nail curving was obtained in all
patients, we feel that the combination of local flap
and nail bed grafts provides a distinct advantage over
other options and improves function.
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